Cancer of the vulva
Cancer of the vulva most commonly affects the skin folds around the vagina, called the labia. It isn't very common, but is considered serious because it makes sexual intercourse painful and difficult. If found early, it has a high cure rate.
Causes and incidence
Although the cause of cancer of the vulva is unknown, several factors seem to predispose women to this disease:
❑chronic pruritus of the vulva, with friction, swelling, and dryness
❑ chronic vulvar granulomatous disease
❑ diabetes
❑ hypertension
❑ irradiation of the skin such as nonspecific treatment for pelvic cancer
❑ leukoplakia (white epithelial hyperplasia) — in about 25% of patients
❑ obesity
❑ pigmented moles that are constantly irritated by clothing or perineal pads
❑ sexually transmitted diseases (herpes simplex, condyloma acuminatum caused by human papilloma virus).
Cancer of the vulva accounts for approximately 4% of all gynecologic malignancies. It can occur at any age, even in infants, but its peak incidence is in the mid-60s. The most common vulval cancer is squamous cell cancer. Early diagnosis increases the chance of effective treatment and survival. Lymph node dissection allows 5-year survival in 85% of patients if it reveals no positive nodes; otherwise, the survival rate falls to less than 75%.
Signs and symptoms
In 50% of patients, cancer of the vulva begins with vulval pruritus, bleeding, or a small vulval mass (which may start as a small ulcer on the surface; eventually, it becomes infected and painful), so such symptoms call for immediate diagnostic evaluation. Less common indications include a mass in the groin or abnormal urination or defecation.
Diagnosis
A Papanicolaou smear that reveals abnormal cells, pruritus, bleeding, or a small vulvar mass strongly suggests vulvar cancer. Firm diagnosis requires histologic examination. Abnormal tissues for biopsy are identified by colposcopic examination to pinpoint vulvar lesions or abnormal skin changes and by staining with toluidine blue dye, which, after rinsing with dilute acetic acid, is retained by diseased tissues.
Other diagnostic measures include complete blood count, X-ray, electrocardiogram, and thorough physical (including pelvic) examination. Occasionally, a computed tomography scan may pinpoint lymph node involvement. (See Staging vulvar cancer.)
Treatment
Depending on the stage of the disease, cancer of the vulva usually calls for radical or simple vulvectomy (or laser therapy, for some small lesions). Radical vulvectomy requires bilateral dissection of superficial and deep inguinal lymph nodes. Depending on the extent of metastasis, resection may include the urethra, vagina, and bowel, leaving an open perineal wound until healing — about 2 to 3 months. Plastic surgery, including mucocutaneous graft to reconstruct pelvic structures, may be done later.
Small, confined lesions with no lymph node involvement may require a simple vulvectomy or hemivulvectomy (without pelvic node dissection). Personal considerations (young age of patient, active sexual life) may also mandate such conservative management. However, a simple vulvectomy requires careful postoperative surveillance because it leaves the patient at higher risk for developing a new lesion.
Chemotherapy alone or in combination with radiation therapy can be used in advanced cases of vulvar cancer. Cisplatin, fluorouracil, bleomycin, and doxorubicin have shown some effectiveness as a palliative treatment option.
If extensive metastasis, advanced age, or fragile health rules out surgery, irradiation of the primary lesion can offer palliative treatment.
Special considerations
Patient teaching, preoperative and postoperative care, and psychological support can help prevent complications and speed recovery.
Before surgery:
❑Supplement and reinforce what the physician has told the patient about the surgery and postoperative procedures, such as the use of an indwelling urinary catheter, preventive respiratory care, and exercises to prevent venous stasis.
❑Encourage the patient to ask questions, and answer them honestly.
After surgery:
❑Provide scrupulous routine gynecologic care and special care to reduce pressure at the operative site, reduce tension on suture lines, and promote healing through better air circulation.
❑Place the patient on an air mattress or convoluted foam mattress, and use a cradle to support the top covers.
❑Periodically reposition the patient with pillows. Make sure her bed has a half-frame trapeze bar to help her move.
❑For several days after surgery, the patient will be maintained on I.V. fluids or a clear liquid diet. As ordered, give her an antidiarrheal drug three times daily to reduce the discomfort and possible infection caused by defecation. Later, as ordered, give stool softeners and a low-residue diet to combat constipation.
❑Teach the patient how to clean the surgical tube thoroughly.
❑Check the operative site regularly for bleeding, foul-smelling discharge, or other signs of infection. The wound area will look lumpy, bruised, and battered, making it difficult to detect occult bleeding. This situation calls for a physician or a primary nurse, who can more easily detect subtle changes in appearance.
❑Within 5 to 10 days after surgery, as ordered, help the patient to walk. Encourage and assist her in coughing and range-of-motion exercises.
❑To prevent urine contamination, the patient will have an indwelling urinary catheter in place for about 2 weeks. Record fluid intake and output, and provide standard catheter care.
❑Counsel the patient and her partner about resumption of sexual activity. Explain that sensation in the vulva will eventually return after the nerve endings heal and that they'll probably be able to have sexual intercourse 6 to 8 weeks following surgery. Explain that they may want to try different sexual techniques, especially if surgery has removed the clitoris. Help the patient adjust to the drastic change in her body image.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Vulva itch
» Next page: Pruritus ani (Professional Guide to Diseases (Eighth Edition))
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